Soft tissue release technique on hip

Posterolateral approach with posterior dislocation of the hip

 With the patient firmly anchored in the straight lateral position, make a slightly curved
incision centered over the greater trochanter. Begin the skin incision proximally at a point
level with the anterior superior iliac spine along a line parallel to the posterior edge of the
greater trochanter. Extend the incision distally to the center of the greater trochanter and
along the course of the femoral shaft to a point 10 cm distal to the greater trochanter (Fig.
3-38A). Adequate extension of the upper portion of the incision is required for reaming of
the femoral canal from a superior direction, and the distal extent of the exposure is
required for preparation and insertion of the acetabular component from an anteroinferior
direction.
 Divide the subcutaneous tissues along the skin incision in a single plane down to the
fascia lata and the thin fascia covering the gluteus maximus superiorly.
 Dissect the subcutaneous tissues from the fascial plane for approximately 1 cm anteriorly
and posteriorly to make identification of this plane easier at the time of closure.
 Divide the fascia in line with the skin wound over the center of the greater trochanter.
 Bluntly split the gluteus maximus proximally in the direction of its fibers and coagulate
any vessels within the substance of the muscle.
 Extend the fascial incision distally far enough to expose the tendinous insertion of the
gluteus maximus on the posterior femur.
 Bluntly dissect the anterior and posterior edges of the fascia from any underlying fibers
of the gluteus medius that insert into the undersurface of this fascia. Suture moist towels
or laparotomy sponges to the fascial edges anteriorly and posteriorly to exclude the skin,
prevent desiccation of the subcutaneous tissues, and collect cement and bone debris
generated during the operation.
 Insert a Charnley or similar large self-retaining retractor beneath the fascia lata at the
level of the trochanter. Take care not to entrap the sciatic nerve beneath the retractor
posteriorly.
 Divide the trochanteric bursa and bluntly sweep it posteriorly to expose the short external
rotators and the posterior edge of the gluteus medius. The posterior border of the gluteus
medius is almost in line with the femoral shaft, and the anterior border fans anteriorly.
 Maintain the hip in extension as the posterior dissection is done. Flex the knee and
internally rotate the extended hip to place the short external rotators under tension.
 Palpate the sciatic nerve as it passes superficial to the obturator internus and the gemelli.
Complete exposure of the nerve is unnecessary unless the anatomy of the hip joint is
distorted.
 Palpate the tendinous insertions of the piriformis and obturator internus and place tag
sutures in the tendons for later identification at the time of closure.
 Divide the short external rotators, including at least the proximal half of the quadratus
femoris, as close to their insertion on the femur as possible. Maintaining length of the
short rotators facilitates their later repair. Coagulate vessels located along the piriformis
tendon and terminal branches of the medial circumflex artery located within the
substance of the quadratus femoris. Reflect the short external rotators posteriorly,
protecting the sciatic nerve.
 Bluntly dissect the interval between the gluteus minimus and the superior capsule. Insert
blunt cobra or Hohmann retractors superiorly and inferiorly to obtain exposure of the
entire superior, posterior, and inferior portions of the capsule.
 Divide the entire exposed portion of the capsule immediately adjacent to its femoral
attachment. Retract the capsule and preserve it for later repair (Fig. 3-38B).
 To determine leg length, insert a Steinmann pin into the ilium superior to the acetabulum
and make a mark at a fixed point on the greater trochanter. Measure and record the
distance between these two points to determine correct limb length after trial components
have been inserted. Make all subsequent measurements with the limb in the identical
position. Minor changes in abduction of the hip can produce apparent changes in leg-
length measurements. We currently use a device that enables the measurements of leg
length and offset (Fig. 3-39).
 Dislocate the hip posteriorly by flexing, adducting, and gently internally rotating the hip.
 Place a bone hook beneath the femoral neck at the level of the lesser trochanter to lift the
head gently out of the acetabulum. The ligamentum teres usually is avulsed from the
 femoral head during dislocation. In younger patients, however, it may require division
before the femoral head can be delivered into the wound.
 If the hip cannot be easily dislocated, do not forcibly internally rotate the femur because
this can cause a fracture of the shaft. Instead, ensure that the superior and inferior
portions of the capsule have been released as far anteriorly as possible. Remove any
osteophytes along the posterior rim of the acetabulum that may be incarcerating the
femoral head. If the hip still cannot be dislocated without undue force (most often
encountered with protrusio deformity), divide the femoral neck with an oscillating saw at
the appropriate level and subsequently remove the femoral head segment with a
corkscrew or divide it into several pieces.
 After dislocation of the hip, deliver the proximal femur into the wound with a broad, flat
retractor.
 Excise residual soft tissue along the intertrochanteric line and expose the upper edge of
the lesser trochanter.
 Mark the level and angle of the proposed osteotomy of the femoral neck with the
electrocautery or with a shallow cut with an osteotome. Many systems have a specific
instrument for this purpose. If not, plan the osteotomy by using a trial prosthesis (Fig. 3-
38C). Use the stem sizeand neck length trials determined by preoperative templating.
 Align the trial stem with the center of the femoral shaft and match the center of the trial
femoral head with that of the patient. The level of the neck cut should be the same
distance from the top of the lesser trochanter as determined by preoperative templating.
 Perform the osteotomy with an oscillating or reciprocating power saw. If this cut passes
below the junction of the lateral aspect of the neck and greater trochanter, a separate
longitudinal lateral cut is required. Avoid notching the greater trochanter at the junction
of these two cuts because this may predispose to fracture of the trochanter.
 Remove the femoral head from the wound by dividing any remaining soft-tissue
attachments. Keep the head on the sterile field because it may be needed as a source of
bone graft.
Technique of soft tissue release
Thickening and contractures of the articular capsule, fibrosis, scar tissue and hyperplastic
osteophytes were removed thoroughly during the operation. For patients with femoral head had
dislocated entirely and did not connect to the true acetabulum, the femoral heads were difficult to
reduce and it was necessary to extensively release periacetabular soft tissue. The four processes
used were as four steps
First, the adductor and parts of the iliotibial tract were split and the superior attachment of the
gluteus maximus to the femoral crest was released.
 Fig 1 Release of the adductor, the iliotibial tract and the gluteus maximus

Second, if reduction was still difficult, the iliopsoas muscle’s attachment to the lesser trochanter
was released but not excised and the attachments of the rectus femoris and sartorius muscles to
the anterior superior iliac spine were released or even transected.

Fig 2 Release of iliopsoas muscle, the rectus femoris and Sartorius muscles

Third, release could be performed with respect to attachments of the piriformis and hamstring
muscles, including the gracilis and biceps femoris, to the ischial tuberosity.
 Fig 3 Release of the piriformis and hamstring muscles

Eventually, osteotomy and migration of the greater trochanter was sometimes necessary to help
reduction and extend the offset to improve abductor muscle strength by moving the greater
trochanter along with the gluteus medius insertion distally.

Fig 4 osteotomy and migration of the greater trochanter

Presedo et al described tbe surgical procedure for the soft tissue release of the hip consisted of an
adductor longus tenotomy, a complete myotoiny of the gracilis, and a psoas recession or an
iliopsoas tenotomy in all of the patients in our series. If hip abduction was <43'' after release of
the adductor longus and the gracilis, a partial myotomy of the adductor brevis was also done
until 45° of hip abduction could be achieved.
Reference
Canale S T, Beaty J H. (Eds.) Old unreduced dislocations In: Campbell’s Operative
Orthopaedics. 11th ed., Philadelphia: Mosby Elsevier; 2008.
Presedo, A., Oh, C.-W., Dabney, K. W., & Miller, F. (2005). Soft-Tissue Releases to Treat Spastic
Hip Subluxation in Children with Cerebral Palsy. The Journal of Bone & Joint Surgery,
87(4), 832–841. doi:10.2106/jbjs.c.01099
Wu, X., Lou, L.M., Li, S.H., Wu, W.P. and Cai, Z.D., 2009. Soft tissue balancing in total hip
arthroplasty for patients with adult dysplasia of the hip. Orthopaedic surgery, 1(3), pp.212-
215.
Wu, X., Li, S.H., Lou, L.M. and Cai, Z.D., 2012. The techniques of soft tissue release and true
socket reconstruction in total hip arthroplasty for patients with severe developmental
dysplasia of the hip. International orthopaedics, 36(9), pp.1795-1801.